Gyn 7: Ovarian Torsion, RPOC, C-Section
What is the presentation of retained products of conception (RPOC)?
Abnormal postpartum vaginal bleeding
What is the presentation of enhanced myometrial vascularity (EMV)?
Abnormal vaginal bleeding
When do uterine dehiscence (scar rupture) happen?
Acute event during subsequent pregnancy
What is the DDX of ovarian torsion?
Appendicitis or hemorrhagic cyst
What are complications if left untreated of retained products of conception (RPOC)?
Bleeding and infection
What is retained products of conception (RPOC)?
Incomplete expulsion of miscellaneous products of conception
Thrombus from postpartum ovarian vein thrombosis (thombophlebitis) is usually found where?
Junction of Rt renal V with IVC
What is the treatment of ovarian torsion?
Laparoscopic detorsion
What side is pelvic congestion syndrome more likely to happen?
Left
Sonographic appearance of bladder flap hematoma
Mass of variable echogenicity & no internal flow
What may enhanced myometrial vascularity (EMV) coexist with?
May coexist with RPOC
What ovary is postpartum ovarian vein thrombosis (thombophlebitis) usually seen in?
Mostly Rt ovarian V
How do you get enhanced myometrial vascularity (EMV)?
Mostly acquired but there are rare congenital situations
When is retained products of conception (RPOC) usually found?
Mostly after 2nd trimester spontaneous abortion or medical termination of pregnancy
What is the location of subfascial hematomas?
Posterior to rectus abdominis muscle
When do you often see enhanced myometrial vascularity (EMV)?
Postpartum or after miscarriage
How is enhanced myometrial vascularity (EMV) acquired?
Prior uterine instrumentation (D&C, myomectomy, C-section)
If calcifications are present in retained products of conception (RPOC) what does this show?
Represents normal term placenta maturation and is highly suggestive of RPOC
Where are most C-section incisions located?
TRV incision in LUS
What age group does ovarian torsion happen in?
Young women <30, or children with ovarian lesions
What is pelvic congestion syndrome?
Chronic pelvic pain associated with pelvic varices (dilation of pelvic veins)
What is ovarian/adnexal torsion?
Complete/partial rotation of ovary *Almost always unilateral
What is the treatment of retained products of conception (RPOC)?
D&C
Bladder flap hematoma
Due to bleeding between LUS & BL
Subfascial hematomas
Due to disruption of inferior epigastric vessels
What is the presentation of pelvic congestion syndrome?
Dull chronic pain
What does a cesarean scar niche/defect look sonographically?
Fluid extending into triangular defect in anterior LUS
How do you get the highest PSV in EMV?
Gradually increase the Doppler scale (PRF) until a few vessels are seen
C-section: Normal sonographic findings after several months
-C-section/hysterotomy scar: thin linear echo/hypoechoic line -C-section scar niche/defect: triangular defect
Sonographic findings of postpartum ovarian vein thrombosis (thombophlebitis)
-Dilated anechoic/hypoechoic tubular structure -Intraluminal echogenic material (thrombus) in OV V with partial or complete absence of flow
Sonographic findings of pelvic congestion syndrome
-Dilated peri-uterine and peri-ovarian veins -Slow venous floe changing to retrograde/reversed flow with valsalva
Sonographic appearance of retained products of conception (RPOC)
-Echogenic mass/tissue within endometrial cavity -Blood flow differentiates RPOC from blood clot -Calcifications
Sonographic appearance of ovarian torsion?
-Enlarged edematous ovary -Multiple peripheral follicles -Absent venous flow -Torsed/twisted pedicle
Sonographic appearance of enhanced myometrial vascularity (EMV)
-Focal area of serpiginous tubular structures -Markedly increased flow -Low-resistance, high velocity flow
What are the causes and risk factors of pelvic congestion syndrome?
-Incompetent ovarian vein (or incompetency of internal iliac vein) -Nutcracker syndrome -May-Thurner syndrome (=iliac vein compression syndrome) -Pregnancy
What is the treatment of pelvic congestion syndrome?
-Medical management (hormones) -Ligation of incompetent ovarian V -Ablation of incompetent veins
What are the causes and risk factors of ovarian torsion?
-Ovarian lesion or cyst -1st trimester or immediately postpartum -Ovulation induction/hyperstimulated ovaries
What is the clinical presentation of ovarian torsion?
-Pelvic pain -N/V
C-section: Normal sonographic findings in initial postpartum period
-Small echogenic foci -Possible heterogeneity in LUS
What are the causes of postpartum ovarian vein thrombosis (thombophlebitis)?
-Venous stasis postpartum -Spread of puerperal infection
When is postpartum ovarian vein thrombosis (thombophlebitis) usually seen?
Uncommon; usually seen 48-96 hours after delivery or miscarriage/abortion
Enhanced myometrial vascularity (EMV) was formerly known as what?
Uterine arteriovenous malformations (AVM)
What is the gold stand for Dx for pelvic congestion syndrome?
Venography
In ovarian torsion, what vasculature is obstructed first?
Venous
